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r type. , „ , Farm Approved,OMB No.2050-0039 UNIFORM HAZAk?D3QUS t Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number CC WASTE MANIFEST - 83 - c' F L G 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) 1010 Indurtnal DiW Get"t.CA S.Transporter 1 Company Name I32W U.S.EPA ID Number AdMCed CheMi0al Tfansprxt InC./DBA ACTENVIRO CA 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number A �.hetyiiew Tre*frllwst 6133�BW W NI D00 AI t* M 87107FFacility'sarei: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class.ID Number, 10.Containers HM and Packing Group(if any)) 11.Total 12.Unit No. Type Quantity WuVol. 13.Waste Codes 1Non-RCRA Hazardous Waste Liquid(0itj P 221 w c� 3. 4. 14.Special Handling Instructions and Additional Information Pmjed Nm*w 1818M Do=rwt# 0219132 1) ACT6448D TH 4. An LLIX30 -D M 15. GENERATOR'SIDFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledrpiacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and t am the Primary Exporter,i certify that the contents of this consignment conform to the Perms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(ff I am a large quantity generator)or(b)(if i am a small quantity generator)is true. Generator'slOfferor's PrintedtTyped Name Signature Month Day Year 16.International Sl ipmems i— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: _ Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Tr porter 1 Prin N e Signature Month Day Year CL t1 ' -$ _ _ ansporter 2 Pdn rT Name Signature GC Month Day Year t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b,Alternate Facility for Generator) U,S.EPA ID Number C3 LL Facility's Phone: LU 18c.Signature of Alternate Facility(or Generators Month Day Year Q Z C19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 i• 2. 3. 4. 141 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed.Typed Name Signature"' Month Day Year rt r - EPA Form 8700-22(Rev.12-17) Previous editions re obsolete. w DESIGNATED FACILITY TO GENERATOR